An Introduction to 4D View TM (Version 5.0)

Transcription

1 9 An Introduction to 4D View TM (Version 5.0) Hans Peter Dietz This book includes a DVD that contains a version of the software 4D View (version 5.0), courtesy of GE Medical, Kretz Ultrasound, Zipf, Austria. To allow you to practice with this software, we have included 16 de-identified volume datasets. This chapter will give an overview of the functionality of this software and take first-time users through the basic steps of performing an analysis in patients with lower urinary tract symptoms and/or pelvic floor dysfunction. After installation on a PC running Windows 2000 or XP/XP Professional, preferably a Pentium IV, a screen showing the program version becomes visible. Click on this screen. Via the File pulldown menu on the left (see Figure 9.1, long arrow), any GE Kretz compatible volume data file can be opened. Incidentally, the file menu also allows for export of bitmaps ( Export graphic ) and AVI videoclips ( Export 4D Img. Cine Sequence ). Most options in the File menu are also accessible via a vertical bar of icons on the far left of the screen (short arrow). The datasets included on the DVD should be visible on clicking Open. Please open Case 1 in the folder De-identified volume data. It is a single static volume dataset of about 5 MB, obtained at rest. This should result in appearances similar to Figure 9.1. The black workspace shows the three orthogonal planes A (midsagittal, top left), B (coronal, top right), and C (axial, bottom left) plus a rendered volume (bottom right). The rendered volume shows a semitransparent representation of all voxels (volume pixels) in the region of interest or ROI, i.e., the box visible in the orthogonal planes (thin arrows). The green line at the top of the box represents the rendering direction, i.e., the direction in which the rendering algorithm analyzes the volume data. This function is accessible via the Settings pulldown menu ( ROI direction ) in case you want to explore the effect of altering the rendering direction. We ll start with some simple two-dimensional (2D) measurements. To optimize for this, please click on the Sectional Planes button (Figure 9.2, arrow) in the Visualization menu on the far right. This should make the rendered volume and the region of interest box disappear (see Figure 9.2). 104

2 Chapter 9 An Introduction to 4D View TM 105 Figure 9.1. Standard orthogonal views on 4D View. You can manipulate all three planes arbitrarily either by clicking on the image itself (e.g., the A plane), or by using the three control sliders immediately below the workspace ( Rotation X, Rotation Y, Rotation Z ). Moving the mouse cursor over the A plane and left clicking changes your arrow into a small icon. This icon will vary depending on how close to the center of the image (identified by a small yellow dot in the plane that s currently active) you are. Please try and drag this icon and observe the effect on your screen. Rotating the A plane image may result in appearances such as in Figure 9.3, or (more likely) something a lot more confusing. Once you are well and truly lost, please click the Init button (Figure 9.3, long arrow) to revert to the appearances in Figure 9.2. The three buttons to the left of Init, incidentally, allow you to select the active plane without clicking on the plane in question. (Tip: The Init option will come in handy whenever appearances on your screen deviate markedly from the figures given in this chapter which is likely to happen many times. However, if you d rather not lose whatever you ve done until that point in time e.g., altered image settings the Orient. Help button (small arrow) under Init may be more useful, giving you a graph of the location of your currently selected plane in the entire volume.) To perform some basic measurements in the A plane, let s enlarge the top left hand part of the workspace. Please click on the right-hand button

3 Figure 9.2. Sectional planes. Figure 9.3. Rotating the A plane.

4 under Display Format which allows the currently active plane (which should be the A plane) to fill the workspace. The screen should now look like Figure 9.4. If your image should not be exactly centered (i.e., if the A plane does not show the urethra well), use the Ref slice control for adjustment (short arrow in Figure 9.4). Once you re happy with the appearance of your A plane, please click on Measure (Figure 9.4, long arrow). The 4D View measurement package will take some seconds to load. Because there currently is no application Pelvic Floor yet, we ll use the Generic menu. This should give you the appearance shown in Figure 9.5. By clicking on Generic Dist (Figure 9.5, long arrow) and Dist 2 point (short arrow), you should be able to measure, e.g., bladder neck position relative to the symphysis pubis (see Figure 9.5) and detrusor wall thickness (not that easy here because the bladder is completely empty). By clicking on Generic angle and Angle 2 line you should be able to measure any angle you may want to determine, e.g., retrovesical angle or the levator plate angle. To perform measurements in the C plane, you need to click Main Menu (bottom right corner) and the left button under Display Format. Rotating the A plane (see Figure 9.3) will change the appearances of the C plane until the C plane represents the minimal dimensions of the hiatus. Experiment Chapter 9 An Introduction to 4D View TM 107 Figure 9.4. Measurements.

5 108 H.P. Dietz Figure 9.5. Measuring distances. with moving the central marker in the A plane up/down and left/right before rotating. (Tip: If a small double-sided arrow comes up instead of the bulls-eye, you ve clicked on the image too far from the central marker.) Remember the Init button: it will likely take several attempts until you have appearances similar to Figure 9.3. Once this is the case, select the C plane and click the right-hand button under Display Format to enlarge the C plane. Then rotate the C plane by clicking on it about 1 2 cm from the central marker, and drag the image until the hiatus assumes appearances as in 9.6. You may also drag the control Magn. under the right-hand corner of the work area in order to make sure that the feature you want to measure fills the screen. (Tip: If you can t see the Magn. control, you re probably not in the Main Menu. You can always get there by clicking the Main Menu button. If you can t see that button, you re already there.) Once you re back in the Measure menu you should see an image similar to Figure 9.6. Now you should try and measure an area, e.g., the hiatal area as in Figure 9.6, by clicking Generic Area and Area Trace. (Tip: At this stage, you re probably cursing your track-pad or mouse, and searching frantically for a decent mouse pad. A graphic tablet, if available, is likely to give superior results.) At this stage, let s try and optimize image quality a bit further. This is likely to be necessary for many (if not all) of the volume datasets included on the DVD. Please click Main Menu in the bottom right-hand corner and

6 select Image settings next to the Measure button. This should give you the appearances shown in Figure 9.7. Please experiment by dragging the controls Bias and Pos until you re happy with the image (Figure 9.7, long arrow). There also is an option SRI (see Chapter 3) which improves resolution by speckle reduction (short arrow). SRI comes in six steps; the author usually selects steps 4 or 5. (Tip: SRI may result in irritating whorl-like artifacts, especially when processing volumes obtained by older systems. It s a matter of trial and error.) While we re in the C plane, let s also try another recent innovation, Tomographic Ultrasound Imaging. In the Main Menu, you ll find a button TUI, situated in the Visualisation submenu on the right (Figure 9.8, long arrow). Clicking on this button will give you the standard TUI screen, containing a reference plane in the top left-hand corner and seven axial slices at predetermined intervals filling the rest of the workspace. It should look approximately like Figure 9.8. These intervals can be adjusted with the TUI distance control (short arrow). You may also want to increase the number of slices via Slices:, + and change which ones are shown in the workspace by using TUI slices, Prev, and Next in the bottom right corner. Now let s do some dynamic measurements and start using the 4D capabilities of 4D View. For this purpose, please go back to the File menu and load Case 5. This is a cineloop of dozens of volumes and therefore much larger in size, about 142 MB. Older PCs will require some time to upload Chapter 9 An Introduction to 4D View TM 109 Figure 9.6. Measuring angles.

7 Figure 9.7. Optimizing image quality. Figure 9.8. Tomographic ultrasound imaging.

8 this dataset. It may be necessary to copy the files to your computer s hard disk before starting work. The resulting image should look much like Figure 9.9, once you ve clicked on Sect. Planes to get rid of the rendered volume. Please feel free to optimize appearances by using Magn., Ref slice, and Image settings. You ll notice that there is a sliding bar in the bottom right-hand corner of the workspace (Figure 9.9, long arrow). Please click on the bar and move it by dragging the indicator (short arrow). (Tip: If the image suddenly seems independent of what you re doing, i.e., it s moving of its own accord, then you haven t clicked on the right spot. Clicking anywhere on the bar activates the cineloop. Stop it by clicking again, then click and hold the indicator.) This lets you replay the whole cineloop of volumes, in this case a Valsalva maneuver. Please stop the cineloop (by clicking anywhere on the bar, or by letting go of the sliding control if you re dragging it) near the start of the cineloop. Select the A plane and go through the steps illustrated above (Figures 9.4 and 9.5) in order to obtain the vertical distance between inferior symphyseal margin and the bladder neck similar to Measurement 1 in Figure 9.5. The vertical distance between inferoposterior symphyseal margin and bladder neck should be about mm. Now go back to Main Menu. Drag the cineloop control until there is maximal displacement of the bladder neck (see Figure 9.10) and measure Chapter 9 An Introduction to 4D View TM 111 Figure 9.9. The cineloop control bar.

9 112 H.P. Dietz again. Do make sure you re able to identify the inferoposterior margin of the symphysis pubis on the frames you select for measuring it s very close to the edge of the image in this volume. Once you have identified a frame that shows a maximal Valsalva (before you select the Measure menu), you ll have to use the Ref slice control in order to visualize the bladder neck it has moved somewhat laterally of the reference plane. There is some funneling although it s not very clear because of artifact in the near field (see Figure 9.10, white arrow). This should give you a measurement of about 8 10 mm for the position of the bladder neck on maximal Valsalva, which is negative because the bladder neck is now caudal to the symphyseal margin. On deducting this second measurement from the first, you arrive at approximately 29 ( 9) = 38 mm of bladder neck descent on Valsalva. And while we re at it, you could also measure maximal descent of the bladder, uterus (Figure 9.11, long arrow), and rectal ampulla (short arrow) against the inferior symphyseal margin (see also Chapter 4). The uterus remains 3.9 mm above the reference line, the rectal ampulla descends to 11.4 mm below. The lowest point of the bladder is virtually at the level of the bladder neck, and the measurement for maximal bladder descent, 8.5 mm below the symphysis, is therefore very close to the measurement obtained in Figure Let s see what else we can do with this cine volume dataset. By all means, have a look at the axial (C) plane it s definitively not normal. In this case, Figure Measuring bladder neck descent.

10 Chapter 9 An Introduction to 4D View TM 113 Figure Measuring pelvic organ descent. the abnormality is best seen on a rendered volume though. Click Init in the main menu, click Render, then optimize image settings. You can change image settings separately for cross-sectional planes A, B, C ( 2D ), and the rendered volume (3D) by selecting one or the other at the top right, once you re in the Image Settings menu. The result should be something close to Figure Please select Main Menu and then click on the box, i.e., the perimeter of the region of interest (ROI) in the A plane (long arrow), and try and manipulate it. You can shrink or enlarge the box, even change the course of the green line by clicking directly on it. Most of those effects can also be achieved by using the controls ROI X, ROI Y, and ROI Z on the bottom left (short arrows). To shift the region of interest up or down, please go to Main Menu, select the C plane, and use the Ref slice control on the bottom left. Click the right button under Display Format to enlarge the rendered volume. The result should look approximately like Figure 9.13, which shows a small left-sided defect of the pubovisceral muscle (long arrow). Use the cineloop control (short arrow) to observe how the levator hiatus enlarges on Valsalva ( ballooning ). You may want to select Measure and determine the area of the hiatus on Valsalva, which should be in the order of cm 2 (see Figure 9.14). Incidentally, you may have noticed that this small defect becomes virtually invisible on Valsalva (arrow) as the area of interest gets flattened against the pelvic sidewall (see Chapter 6).

11 Figure Region of interest controls. Figure Left-sided avulsion in a rendered volume.

12 Chapter 9 An Introduction to 4D View TM 115 Figure Levator ballooning in a rendered volume. Congratulations for reaching the end of this short course! You should now be able to analyze all 16 volume datasets on 15 virtual patients included on the DVD. The first and fifth you ve already encountered. Usually, a full examination will include volumes obtained on levator contraction in order to be able to assess pelvic floor muscle function. To simplify matters, I ve given two datasets only in Case 2 in order to demonstrate the effect of levator activation. In all other cases (4 15), there is only one cine volume dataset, comprising volumes from resting to maximal Valsalva. The settings have been optimized for brightness, contrast, magnification, and speckle reduction, but of course you re welcome to change these settings as you see fit. In the Appendix, I ve added (hypothetical) reports describing those virtual patients in order for you to be able to check your findings against mine. As regards numerical measurements, I d suggest that you recheck your methodology if your figures differ by more than 20% from those given in the reports. You re welcome to me with specific questions or comments at hpdietz@bigpond.com. Good luck! H.P. Dietz Sydney, December 2006

13 Appendix Cases for Virtual Scanning Using 4D View Hans Peter Dietz Case 1: Static Volume at Rest, Normal Anatomy I saw your above patient yesterday for a pelvic floor ultrasound. As you know, she has been getting recurrent urinary tract infections, about five over the last year. She was examined supine and after voiding, using a GE Kretz Voluson 730 expert system with 8 4 MHz volume transducer. Unfortunately, our system crashed halfway through the examination, leaving me with just the static volume ultrasound, which is what I can report to you today. There was no postvoid residual. The urethra and vagina appeared normal, in particular there was no evidence of a urethral diverticulum or stenosis. Detrusor wall thickness was normal at 2.9 mm. The levator ani muscle and hiatus were completely normal, measuring about 12 cm 2 at rest. Because of the absence of volumes on Vasalva, I m unable to comment on pelvic organ descent or prolapse. Interpretation: Normal anatomy at rest. I hope to have been of assistance. 117

14 118 H.P. Dietz Case 2: Normal Anatomy (2a), Pelvic Floor Contraction (2b) Thanks for referring this 21-year-old primigravid woman at 30 weeks gestation who is presenting with a sensation of prolapse, or laxity, without there being, as I understand from your referral, any clinical findings. I gather that she is a women s health physiotherapist who wants to know whether her pelvic floor is normal. 2D: There was no postvoid residual. The urethra appeared normal. The bladder neck descended only 9 mm, with 10 of urethral rotation and no funneling. There was no other evidence of pelvic organ descent. The rectovaginal septum was intact. Detrusor wall thickness was normal at 3.1 mm. 3D: The pubovisceral muscle was intact bilaterally and invariably activated whenever the patient increased intraabdominal pressure. The hiatus on Valsalva measured only 11 cm 2. The patient was able to perform a symmetrical pelvic floor contraction which reduced the hiatus by 7 mm in the midsagittal diameter, and to about 8 cm 2 in the axial plane. Interpretation: Normal pelvic floor anatomy and function.

15 Appendix 119 Case 3: Cystocele I, Elevated Detrusor Wall Thickness Thanks for referring this 25-year-old woman who is presenting with symptoms of irritable bladder. There is urgency, urge incontinence, frequency, and nocturia, as well as occasional stress incontinence. She is mother of two children born by normal vaginal delivery. 2D: There was no postvoid residual. The urethra appeared normal. The bladder neck descended by about 30 mm, with 80 of urethral rotation but no funneling. There was no other evidence of pelvic organ descent. Detrusor wall thickness was abnormal at 6.1 mm. 3D: The pubovisceral muscle was intact bilaterally and appeared to be rather substantial, especially on the left. The hiatus opened to 21 cm 2 on Valsalva, which is normal. Interpretation: Mild cystourethrocele with urethral rotation and opening of the retrovesical angle, but no funneling. Elevated detrusor wall thickness which is associated with detrusor overactivity. Otherwise normal pelvic floor anatomy.

16 120 H.P. Dietz Case 4: Cystocele I, Funneling, Stress Incontinence Thanks for referring this lady who is presenting with symptoms of severe stress incontinence. There are no other symptoms of bladder or bowel dysfunction. 2D: There was no postvoid residual. The urethra was normal. The bladder neck descended 27 mm on Valsalva, with 50 of urethral rotation, an open retrovesical angle (180 ), and marked funneling. No cystocele. Detrusor wall thickness was normal at 2.6 mm. No central or posterior compartment descent. 3D: The pubovisceral muscle was intact bilaterally, and there was no ballooning, with the hiatus measuring less than 20 cm 2 on Valsalva. There was normal paravaginal tenting bilaterally. Interpretation: Mild bladder neck descent with marked urethral funneling, indicative of a low-pressure urethra and likely to be associated with urodynamic stress incontinence. No prolapse. Good levator and hiatal anatomy.

17 Appendix 121 Case 5: Cystocele II, Uterine Prolapse I, Right-sided Levator Avulsion As you re aware, this 32-year-old woman has noticed a lump downbelow after the delivery of her first child some 4 months ago. There are no symptoms of bladder or bowel dysfunction. 2D: There was no postvoid residual. The urethra appeared normal. We saw 36 mm of bladder neck descent on Valsalva, with the retrovesical angle opening to 180, 90 of urethral rotation, and some funneling. A cystocele descended to about 8 mm below the symphysis, the uterus to 4 mm above, and the rectal ampulla to 12 mm below. There was no true rectocele or defect of the rectovaginal septum, but possibly a minor degree of rectal intussusception or internal rectal prolapse. Detrusor wall thickness was abnormal at 5.4 mm. 3D: There was some asymmetry of the pubovisceral muscle with a moderate-sized defect of the entire pubovisceral muscle on the left. On Valsalva, there was moderate ballooning of the hiatus to 36 cm 2. Interpretation: Mild moderate cystocele with open retrovesicle angle and funneling. Minor degree of uterine prolapse. Perineal hypermobility but no true rectocele. Left-sided avulsion defect of the pubovisceral muscle and moderate ballooning. Significant risk of prolapse recurrence after reconstructive surgery.

18 122 H.P. Dietz Case 6: Rectocele II Thanks for referring this 72-year-old woman who is presenting with symptoms of prolapse, incomplete bowel emptying and straining at stool, as well as occasional fecal incontinence. There are no urinary symptoms apart from mild frequency and nocturia. 2D: There was a postvoid residual of less than 30 ml. The urethra was normal. The bladder neck was obscured by a fairly large rectocele on Valsalva but did not seem to descend more than 2 cm on Valsalva, with about 30 of rotation. No cystocele. Detrusor wall thickness was normal at 3.9 mm. The main finding was a large rectocele, reaching to about 28 mm below the symphysis pubis, of a depth of 30 mm on Valsalva. A transverse defect of the rectovaginal septum was evident even at rest, at the level of the anorectal junction. No rectal prolapse or intussusception. The internal and external anal sphincters were intact. 3D: The pubovisceral muscle seemed intact bilaterally, and the hiatus enlarged to only 25 cm 2 on Valsalva, which is normal. Interpretation: Large rectocele caused by a transverse defect of the rectovaginal septum at the level of the anorectal junction. No major morphologic abnormality of the levator ani; no ballooning of the hiatus.

19 Appendix 123 Case 7: Previous Burch Colposuspension, Rectoenterocele II, Severe Ballooning Thanks for referring this 68-year-old woman who is presenting with symptoms of prolapse about 5 years after a Burch colposuspension. There also is incomplete bowel emptying and straining at stool, and she has had several urinary tract infections (UTI) over the last year. 2D: There was a postvoid residual of approximately 40 ml. The urethra showed the obvious distortional effects of a colposuspension. There may be some urethral stenosis as a result. The bladder neck was well elevated, with only 4 mm of bladder neck descent on Valsalva and an intact retrovesical angle. No cystocele. Detrusor wall thickness was normal at 4.5 mm. The main finding was a moderate rectoenterocele, with the enterocele dominant and reaching about 18 mm below the symphysis pubis. The rectocele reached to 14 mm below and measured at a depth of 18 mm. 3D: The pubovisceral muscle seemed intact bilaterally, if somewhat thin, more so on the left. However, there was marked ballooning of the hiatus to 42 cm 2. Interpretation: Well-supported bladder neck after Burch colposuspension which may be slightly on the tight side. Moderate rectoenterocele, with the enterocele present at rest and clearly the dominant feature. No major morphologic abnormality of the levator ani, but marked ballooning of the hiatus.

20 124 H.P. Dietz Case 8: Cystocele III after Burch and Zacharin Procedure, Voiding Dysfunction Thank you kindly for referring this 62-year-old woman who is presenting with symptoms of recurrent prolapse after a vaginal hysterectomy and anterior/posterior (A/P) repairs in 1980, a Burch colposuspension 12 years ago, and a Zacharin abdominoperineal levatorplasty plus sacrocolpopexy in She describes urge incontinence, hesitancy and recurrent urinary tract infections, as well as symptoms of chronic constipation and prolapse. 2D: There was a postvoid residual of 120 ml. The urethra and bladder neck showed the effects of a colposuspension but were otherwise normal. We measured 13 mm of bladder neck descent, with intact retrovesical angle and no funneling. There was a large high cystocele to 26 mm below the symphysis pubis but no other evidence of prolapse. The cul-de-sac remained about 2 cm above the symphysis pubis, and there was no rectocele. Detrusor wall thickness was normal at 3 mm although this finding should be regarded with caution because of the high residual. 3D: The pubovisceral muscle seemed intact. Typical for a Zacharin levatorplasty, there was a thick scar plate anterior to the rectum, linking the lateral aspects of the pubovisceral muscle. This scar plate extended over at least 2.5 cm in a craniocaudal direction, ventral to the anorectal junction. However, there still was some ballooning of the hiatus to 33 cm 2. Interpretation: Well-supported bladder neck after Burch colposuspension. Moderate high cystocele. Good vault and posterior compartment support. Intact levator ani with evidence of effective Zacharin levatorplasty. There may be a degree of stenosis at the level of the anorectal junction. Mild hiatal ballooning. Likely mild to moderate voiding dysfyunction.

21 Appendix 125 Case 9: Gartner Cysts As you re aware, this 30-year-old woman recently had a transvaginal ultrasound during which cystic structures were noted in the anterior vaginal wall. She is mother of one child born by normal vaginal delivery. There are no symptoms of bladder or bowel dysfunction. 2D: There was a small postvoid residual of 60 ml. The urethra appeared normal. We saw 13 mm of bladder neck descent on Valsalva, with the retrovesical angle on Valsalva at 130, 40 of urethral rotation, and no funneling. No pelvic organ prolapse. Detrusor wall thickness was normal at 2.7 mm. There were multiple cystic structures in the anterior vaginal wall without obvious connection to the urethra, and no internal echoes. They extended close to the ureteric orifices but again appeared separate from those structures. 3D: There was no asymmetry of the pubovisceral muscle, no evidence of defects. On Valsalva, there was only very minor opening of the hiatus to 17 cm 2. Interpretation: Multiple cystic structures situated in the anterior vaginal wall, up to 2 3 cm in diameter. No obvious connection to lower or upper urinary tract, but the cysts extend close to the ureters bilaterally and surround the urethra, especially on the left. These structures are very likely to be attributable to Gartner duct cysts and best left alone unless clearly symptomatic.

22 126 H.P. Dietz Case 10: Cystocele II, Uterine Prolapse II, Bilateral Avulsion I ve had the honor of seeing your above patient for a pelvic floor ultrasound. As you re aware, this 37-year-old woman had her first child by rotational forceps, about 9 months ago. She says that she hasn t been the same since. There is urgency, urge incontinence, and a sensation of prolapse as well as incomplete bowel emptying. 2D: There was a postvoid residual of approximately 70 ml. The urethra appeared normal. We saw 44 mm of bladder neck descent on Valsalva, with the retrovesical angle opening to 180, 80 of urethral rotation, but no funneling. A cystocele descended to about 15 mm below the symphysis; the uterus to 13 mm below. Detrusor wall thickness was normal at 3.5 mm. There was no defect of the rectovaginal septum. 3D: There was a major bilateral avulsion injury of the pubovisceral muscle, worse on the right, with complete loss of paravaginal tenting. The hiatus measured more than 6 cm in the coronal plane, and the defects measured almost 3 cm in width. Although dimensions in the sagittal plane remained reasonable, the severe damage to levator insertions bilaterally caused marked ballooning of the hiatus to 43 cm 2. Interpretation: Moderate cystocele with open retrovesicle angle (RVA) but no funneling. Moderate uterine prolapse. Normal posterior compartment. Major bilateral avulsion defect of the pubovisceral muscle and severe ballooning. Marked risk of prolapse recurrence after reconstructive surgery. Her anterior compartment prolapse is probably incurable unless one uses mesh inter position. Anorectal function may require further investigation.

23 Appendix 127 Case 11: Rectal Prolapse after Monarc, Apogee Procedures Thanks for referring this woman who is presenting with symptoms of obstructive defecation and dyschezia 4 months after an apparently successful repair of a posthysterectomy vault prolapse by Apogee mesh. As you re aware, she has had multiple anti-incontinence and prolapse procedures in the past. There is no incontinence. 2D: There was a postvoid residual of approximately 40 ml. The urethra was normal. There was a transobturator suburethral sling in a typical midurethral position. It seemed under moderate tension, as evidenced by its c shape on Valsalva, but not unduly obstructive because there still was a gap of 13 mm between tape and symphysis pubis on Valsalva. The bladder neck descended by 17 mm on Valsalva, without significant rotation. No cystocele. Detrusor wall thickness was normal at 4.5 mm. The main finding was an enterocele reaching about 10 mm below the symphysis pubis. It seemed to develop posterior to the Apogee mesh and was starting to invaginate the rectum, causing an internal rectal prolapse. 3D: The pubovisceral muscle showed marked asymmetry. Whereas there was no evidence of an avulsion injury, the left pubovisceral muscle appeared deficient, especially in its more cranial aspects, resulting in marked asymmetrical ballooning to about 40 cm 2. The enterocele developed mainly on the left as a consequence. Interpretation: Both Monarc and Apogee mesh are in their typical locations. There is no evidence of vaginal prolapse recurrence. As preoperatively, there is ballooning of the hiatus to 40 cm 2, and evidence of left-sided impairment of the pubovisceral muscle. The previously visible enterocele is still present and now seems to develop posterior to the mesh, into the anal canal, resulting in an incipient rectal prolapse. A colorectal assessment is recommended.

24 128 H.P. Dietz Case 12: Cystocele II, Rectocele II, Voiding Dysfunction Thanks for referring this 64-year-old woman who is presenting with symptoms of prolapse and recurrent urinary tract infections. There are no other symptoms of bladder or bowel dysfunction. She is mother of three children born by normal vaginal delivery and had a vaginal hysterectomy about 20 years ago. 2D: There was a postvoid residual of 90 ml. The urethra showed several hyperechogenic foci which are of uncertain significance. The bladder neck descended 37 mm on Valsalva, with 120 of urethral rotation, a retrovesical angle that remained at 130, and no funneling. There was marked urethral kinking of 90, with the proximal urethra closely tethered to the pubis. The cystocele reached to 20 mm; a rectocele to 15 mm below the symphysis. Its depth was measured at 13 mm only. Detrusor wall thickness was normal at 4 mm. 3D: There was a left-sided pubovisceral muscle avulsion injury of up to 17 mm in width at the level of the hiatus and extending cranially for at least 25 mm. The upper aspects of the left puborectalis muscle seemed to be almost completely absent, with the defect measuring up to 35 mm at this level. These was mild ballooning to 31 cm 2 on Valsalva. Interpretation: Moderate cystocele with intact retrovesical angle and significant urethral kinking. Likely mild moderate voiding dysfunction. Small rectocele. Marked left-sided pubovisceral muscle injury, mild ballooning. This woman seems to be at increased risk of prolapse recurrence in case surgery is undertaken. Prolapse correction may result in better voiding, but may also unmask potential occult stress incontinence.

25 Appendix 129 Case 13: Bilateral Avulsions, Perigee Procedure Thanks for referring this 37-year-old woman who had a Perigee anterior vaginal wall repair about 3 months ago for anterior and central-compartment prolapse. She is currently completely asymptomatic and very happy with the outcome. 2D: There was no postvoid residual. The urethra was normal. The bladder neck was well elevated, with only 8 mm of bladder neck descent on Valsalva and a retrovesical angle of 140. No cystocele. The Perigee was situated between urethra and cervix and in a typical, functional position. The uterus descended to about the symphysis pubis, and the posterior compartment was well elevated. Detrusor wall thickness was normal at 4 mm. 3D: There was a major bilateral avulsion injury to the pubovisceral muscle measuring 26 mm in width and extending over at least 2 cm in a craniocaudal direction. On Valsalva, the hiatus measured about 8 cm in the coronal plane which is unusually wide. The Perigee implant seemed to traverse these defects. There was moderate ballooning of the hiatus to 36 cm 2. Interpretation: Well-supported anterior and posterior compartment after Perigee mesh which is in a typical position and traverses a major bilateral avulsion injury. Mild uterine descent. Moderate ballooning.

26 130 H.P. Dietz Case 14: Mixed Incontinence after Tensionless Vaginal Tape (TVT) and Burch Colposuspension Thanks for referring this 59-year-old woman who is presenting with symptoms of urgency and urge incontinence as well as recurrent stress incontinence. There are no other symptoms of bladder or bowel dysfunction. She is mother of two children born vaginally. In 1989 she had a total abdominal hysterectomy (TAH) and colposuspension, and you performed a TVT for recurrent stress incontinence a few years ago. 2D: There was a postvoid residual of about 20 ml. The urethra was normal, but the bladder neck was massively distorted because of the colposuspension. The bladder neck descended about 15 mm on Valsalva. There was no urethral rotation but marked funneling. There was a small high cystocele which remained 6 mm above the symphysis. The vault was well supported as was the posterior compartment. The TVT was in a typical midurethral position and did not seem to be particularly tight, with a minimum gap of 13 mm between tape and symphysis. Detrusor wall thickness was normal at 2.8 mm. 3D: The levator ani muscle and hiatus appeared normal. There was no ballooning and the hiatus measured about 20 cm 2 on Valsalva. Interpretation: Previous Burch colposuspension still in evidence, small high cystocele. Midurethral TVT which is not unduly obstructive. Marked funneling indicative of a low-pressure urethra. Good central and posterior compartment support; normal levator muscle and hiatus.

27 Appendix 131 Case 15: Urethral Diverticulum As you re aware, this 34-year-old woman has had symptoms of voiding difficulty and dyspareunia for several years. There are no symptoms of bladder or bowel dysfunction apart from the sensation of a lump in the vagina. This frequently is tender on intercourse. She has had no urinary tract infections (UTI) but was investigated by urologic colleagues, with two cystoscopies in 2002 and 2005 reported as normal. 2D: There was no postvoid residual. We saw 28 mm of bladder neck descent on Valsalva, with the retrovesical angle opening to 180, 40 of urethral rotation, and minor funneling. No cystocele, no rectocele. There was a thick-walled (about 3 mm) multicystic complex structure measuring approximately cm surrounding the proximal urethra almost symmetrically in a horseshoe-shaped configuration. It was situated ventral to the proximal urethra and bladder neck. Detrusor wall thickness was normal at 2.5 mm. 3D: There was no major asymmetry of the pubovisceral muscle, although the upper aspects of the left puborectalis muscle seemed thin. On Valsalva, the hiatus reached 26 cm 2 which is normal. Interpretation: Atypical urethral diverticulum ventral and lateral to the proximal urethra, measuring about 2 cm in maximal diameter. There seems to be a diverticular neck about 2.5 cm from the external meatus and 1.5 cm from the internal meatus at about 12 o clock. Mild rotatory descent of the bladder neck with opening of the RVA and funneling. There is an increased likelihood of stress incontinence after removal of the diverticulum, which would best be approached through the space of Retzius. No prolapse; no major abnormality of the levator ani.